Provider Demographics
NPI:1710072137
Name:PAYNE, SANDRA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JOHN P RAKUTT DMD PSC
Mailing Address - Street 2:801 BARRET AVENUE #107
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204
Mailing Address - Country:US
Mailing Address - Phone:502-582-2004
Mailing Address - Fax:502-582-2032
Practice Address - Street 1:JOHN P RAKUTT DMD PSC
Practice Address - Street 2:801 BARRET AVENUE #107
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204
Practice Address - Country:US
Practice Address - Phone:502-582-2004
Practice Address - Fax:502-582-2032
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY6437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60064375Medicaid
KY0004999OtherDORAL